HOSPITAL READMISSIONS IN MASSACHUSETTS Zi Zhang, MD, MPH Catherine - - PowerPoint PPT Presentation

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HOSPITAL READMISSIONS IN MASSACHUSETTS Zi Zhang, MD, MPH Catherine - - PowerPoint PPT Presentation

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ACCOUNTING FOR SOCIAL RISK FACTORS IN PUBLIC REPORTING ON UNPLANNED HOSPITAL READMISSIONS IN MASSACHUSETTS Zi Zhang, MD, MPH Catherine Nwachukwu, MPH Bridget Gayer, MS, MPH Christine Loveridge, MPAff Huong Trieu, PhD NAHDO 2019 Health Care

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ACCOUNTING FOR SOCIAL RISK FACTORS IN PUBLIC REPORTING ON UNPLANNED HOSPITAL READMISSIONS IN MASSACHUSETTS

CENTER FOR HEALTH INFORMATION AND ANALYSIS

Zi Zhang, MD, MPH Catherine Nwachukwu, MPH Bridget Gayer, MS, MPH Christine Loveridge, MPAff Huong Trieu, PhD NAHDO 2019 Health Care Data Summit November 6, 2019

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Acknowledgements

2 Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

▪ Workgroup on Social Risk Factors and Readmissions ▪ UMass Medical School Team

Paul D. Allen, MD David Auerbach, PhD Abigail Averbach Katherine Shea Barret Amy Boutwell, MD, MPP Kathryn Britton, MD Ray Campbell Lori Cavanaugh Peggy Chou, MD Clara Filice, MD Kate Fillo Patrick M. Gannon David Garbarino Paula Griswold Carol Gyurina Vivian Haime Paul J. Helmuth, MD Deborah Allwes Largoza Paul S. MacKinnon James Moses, MD Pat Noga, PhD Douglas Salvador, MD Linda Shaughnessy Patricia Toro, MD Lindsey Tucker Arlene Ash, PhD Thomas Land, PhD Wenjun Li, PhD

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Agenda

3 Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

▪ Background ▪ Objectives ▪ Methods ▪ Results ▪ Summary ▪ Next Steps

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▪ There is evidence that social risk factors are associated with access, utilization and quality of health care ▪ Unplanned hospital readmissions adversely impact patient health and are a significant financial burden on the healthcare system ▪ Appropriately accounting for social risk factors in quality and performance measures could have significant implications for improvements in health care delivery and population health

Background

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

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▪ Identify available social risk factor data in the current systems ▪ Determine how to adequately account for social risk factors in hospital readmissions analysis ▪ Incorporate results from analysis in the public reporting on hospital readmissions in Massachusetts

Objectives

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

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CHIA’s All-Payer Readmission Work

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

2008 2010 2012 2014 2018 CMS disease-specific measures for Medicare FFS CMS Hospital-Wide Readmissions (HWR) measure for Medicare FFS SQAC recommends HWR measure CHIA adapts HWR measure for all-payer population CHIA 1st annual readmission report & hospital specific profiles (SFY 2011-2013) CHIA 5th annual readmission report & hospital specific profiles (SFY 2011-2017) 2016 CHIA behavioral health & readmission report (SFY 2014) CHIA 1st ED revisit after inpatient discharge report (SFY 2015)

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Hospital-Wide All-Cause Readmission Measure

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Original Yale/CMS Measure CHIA’s Adapted Version for All- payer

Population

  • Medicare FFS population, 65+
  • All-payer population, 18+

Data source

  • Based on Medicare claims &

enrollment data

  • Based on MA acute care hospital

casemix Hospital Inpatient Discharge Database (HIDD) Exclusions for specialized care

  • Obstetric
  • Cancer
  • Psychiatric
  • Rehabilitation
  • Obstetric
  • Cancer
  • Psychiatric
  • Rehabilitation

Observed Rates

  • Raw rates (unadjusted)

Risk Standardized Readmission Rates (RSRRs)

  • Derived from statistical model.
  • Adjust hospitals’ observed rates for:
  • Age
  • Patient case mix (comorbidities)
  • Hospital service mix (discharge condition)
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Counting “Eligible” Discharges

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

HIDD Adult Discharges 704,607*

Remove discharges that don’t make sense to include Remove discharges for certain specialized types of care

Analytic Cohort 498,493*

  • Missing/invalid SSN
  • Transfers
  • Deaths in hospital
  • Against medical advice
  • Obstetric
  • Cancer
  • Psychiatric
  • Rehabilitation

* Based on SFY 2017 data

Eligible Discharges (before exclusion) 614,566*

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Calculating Readmission Rates

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Number of Readmissions Number of Eligible Discharges Observed Readmission Rate

=

X 100

=

Observed Readmission Rate Hospital-wide Standardized Readmission Ratio* X

* Standardized Readmission Ratio represents the extent to which a hospital has more or fewer readmissions than one would expect based on characteristics of the patients they treat. This ratio is derived by a series of calculations from the output of multiple statistical models. For more information, please see CHIA’s Hospital-Wide Adult All-Payer Readmissions in Massachusetts: SFY 2011-2017: Technical Appendix.

Risk Standardized Readmission Rate

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Current Risk-Adjustment Model for Readmissions

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Discharge level factors

  • Patient Age
  • Patient case mix (31 comorbid

conditions)

  • Hospital service mix (patient’s

discharge condition) Hospital level factor

  • Random intercept for each

hospital Medicine Surgery / Gynecology Neurology Cardiorespiratory Cardiovascular

5 Clinical Cohorts Hierarchical Logit Model

Note: Clinical cohorts and hospital service mix are based on the AHRQ Clinical Classification Software (CCS) grouper. Patient case mix is based on CMS Condition Categories

  • grouper. For more information, please see CHIA’s Hospital-Wide Adult All-Payer Readmissions in Massachusetts: SFY 2011-2017: Technical Appendix.

Predicted # of readmissions Expected # of readmissions Standardized Readmission Ratio (SRR) Risk Standardized Readmission Rate

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Workgroup on Social Risk Factors and Readmissions

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

▪ The workgroup was created to advise CHIA by gathering expert counsel and scientific research to examine the following areas: ▪ How might individual and community-level social risk factors be conceptualized and defined? ▪ What data is necessary and/or available to adequately measure social risk factors? ▪ If applicable, how might social risk factors be appropriately accounted for in CHIA’s public reporting of readmissions and revisits?

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Workgroup on Social Risk Factors and Readmissions

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Kickoff May 2018 Meeting July 2018 Meeting

  • Sept. 2018

Meeting April 2019 Final June 2019

Purpose Introductions Initial Exploration Purpose MA HIDD & Readmissions Stratification vs. Adjustment Discussion Identify analytic tests Review preliminary analysis Discussions & Recommendations

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▪ Adopt a social risk factor framework ▪ Identify available social risk factor data ▪ Enhance existing risk-adjustment model

Solution

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

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Conceptual Framework of Social Risk Factors for Health Use, Outcomes, and Cost

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

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Data Sources for Available Social Risk Factors

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Patient-level variables:

  • Sex
  • Race
  • Homeless status
  • Insurance type (incl. dual-eligibility proxy)

Community-level factors:

  • Poverty
  • Housing
  • Employment
  • Education

MA Hospital Inpatient Discharge Database (HIDD) US Census 2010 & American Community Surveys (2015- 2017)

Linked by patient zip code

Data Sources

▪ A three-year aggregate dataset is created from these sources. Missing data is dropped. For example, if missing zip code, community-level factors are not included.

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Original and Enhanced Risk-Adjustment Models

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Original model (Yale/CMS): CHIA’s current risk-adjustment model for readmissions adjusts for patient age, patient case-mix, and hospital service mix Enhanced model: Original model plus the additional patient- and community-level factors Patient-level factors:

  • Sex
  • Race
  • Homeless status
  • Insurance type (incl. dual-eligibility proxy)

Community-level factors:

  • Poverty
  • Housing
  • Employment
  • Education
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Original and Enhanced Risk-Adjustment Models

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Variable Type Description Original Enhanced

Variables in original model

Comorbidities*

X X**

Age

Age as continuous variable Age groups for 18+

Cohort-specific condition categories

X X Patient-level social risk factors

Sex

X

Race

X

Homeless status

X

Insurance type (incl. dual-eligible proxy)

X Community-level social risk factors

Median family income

X

Median home value

X

Percent of employed persons 16+ in white collar occupations

X

Percent of single parent households with dependents under age 18

X

Percent of population ages 25+ with at least a high school education

X

Percent of population on food stamps/SNAP

X

Percent of population who have lived in the same house in the past 12 months

X

Percent of population ages 16+ who are unemployed

X

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Results

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Total Hospital-Level Adjustment: CV Cohort

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Results

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Domain-Specific Hospital-Level Adjustment: CV Cohort

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Results

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Total Hospital-Level Adjustment: Medicine Cohort

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Results

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Domain-Specific Hospital-Level Adjustment: Medicine Cohort

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Results

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Sample Hospital Domain-Specific Hospital-Level Adjustment: Medicine Cohort Regression coefficient (B) Hospital- specific score (S) Amount of adjustment in logit scale (B*S) Adjustment in odds ratio (exp(B*S)) Comorbidity score 0.577

  • 0.151
  • 0.087

0.917 Patient demographic score 0.119

  • 0.137
  • 0.016

0.984 Patient social risk score 0.098

  • 0.019
  • 0.002

0.998 Community score

  • 0.011
  • 0.557

0.006 1.006 Total Net Adjustment

  • 0.099

0.906

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Results

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Change in risk-standardized readmission rates by hospital

Difference in Readmission Rates in Percentage Points

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Results

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

Change in risk-standardized readmission rates by hospital cohort

*Community-High Public Payer (HPP) hospitals are community hospitals that have at least 63% of Gross Patient Service Revenue attributable to Medicare, MassHealth, and

  • ther government payers, including the Health Safety Net.

*

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▪ Accounting for social risk factors is important for fair and accurate reporting of hospital quality and performance ▪ Social risk factors significantly influence risk for readmissions and should be considered routinely in risk adjustment ▪ Comorbid conditions are still the dominant risk factors for adjustment ▪ Incorporating social risk factors in risk-adjustment does not mask differences between hospitals (range of 4.8 percentage points) ▪ Proper adjustment for social risk factors works in favor of hospitals serving higher proportions of vulnerable patients

Summary

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

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▪ Incorporate community-level data for patients from neighboring states ▪ Work with hospital stakeholders to standardize zip code on discharges flagged as homeless ▪ Linkage to member eligibility data for an enhanced indicator of dual- eligibility status

Next Steps

Accounting for Social Risk Factors in Public Reporting on Unplanned Hospital Readmissions in Massachusetts | November 6, 2019

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Questions?

27 Who are Lower-Wage Firms and How are Their Employees Covered for Healthcare? | June 23, 2018

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▪ For questions, please contact: Zi Zhang, MD, MPH Massachusetts Center for Health Information and Analysis zi.zhang@state.ma.us

Contact Information

28 Who are Lower-Wage Firms and How are Their Employees Covered for Healthcare? | June 23, 2018